Eldad Erez

Recombinant factor VIIa (NovoSeven®) as a hemostatic agent after surgery for congenital heart disease

Background : Postoperative bleeding and blood product requirements can be substantial in children undergoing open‐heart surgery, and reexploration is required in 1% of cases. Recombinant activated factor VII (rFVIIa, NovoSeven®, NovoNordisk, Denmark) is a hemostatic agent approved for the treatment of hemophilic patients with inhibitors to factor VIII or factor IX. It has also been used with success in other conditions. We present our experience with rFVIIa treatment for uncontrolled bleeding after open‐heart surgery in five pediatric patients.

Surgical management of aortopulmonary window and associated lesions.

BACKGROUND Aortopulmonary window is a rare congenital heart defect commonly associated with other cardiac anomalies. Although single institutional experience is low, several surgical techniques have been reported. The purpose of this study is to describe our approach to the management of aortopulmonary window and its associated lesions. METHODS Between February 1996 and November 2002, 13 patients underwent repair of aortopulmonary window. The age range went from 4 days to 5.5 months (mean 42 +/- 52 days), with 9 patients younger than 1 month old. The weight range was from 1.9 to 6.7 kg (mean 3.5 +/- 1.2 kg). Concomitant cardiac anomalies were present in 11 patients. The major additional anomalies were interruption of aortic arch in 4 patients and tracheal stenosis in 1 patient. Initial diagnoses were made using two-dimensional echocardiography only. RESULTS There was one postoperative death. In general, patients with aortopulmonary window and additional major defects had a prolonged intensive care unit and hospital stay when compared with the other patients. Follow-up time ranged from 2 months to 6.8 years (mean of 2.5 +/- 2.2 years). There were no reoperations and no late deaths. Transcatheter balloon dilatation of the repaired aortic arch was required in 1 patient and of the right pulmonary artery in another. All other patients had good flow to both pulmonary arteries. No residual shunts were detected at the aortopulmonary window site, and pulmonary pressures were normal. CONCLUSIONS Aortopulmonary window may be effectively diagnosed with echocardiography. Early surgical treatment (neonatal period, if possible) is safe and associated with the best long-term results, even in the presence of other cardiac anomalies. Complete separation and reconstruction of both aorta and pulmonary arteries under direct vision may prevent recurrence and distortion of adjacent structures.

Thromboxane Production in Human Lung During Cardiopulmonary Bypass: Beneficial Effect of Aspirin?

BACKGROUND Increased systemic levels of thromboxane (Tx) during cardiopulmonary bypass (CPB) in humans have been reported. It is not known whether this reflects a general systemic response to the surgical procedure or an increased pulmonary production of Tx in response to ischemia and reperfusion. METHODS Thromboxane B2 levels were measured in the right atrium and left atrium of 14 patients undergoing coronary artery bypass grafting for angina. Eight patients (group 1) were without aspirin for at least 15 days before operation, and 6 patients (group 2) were treated with aspirin (100 mg/day) for at least 1 month before operation. Levels of TxB2 were determined by enzyme immunoassay after lipid extraction and separation. RESULTS Thromboxane B2 levels were elevated throughout CPB. In group 1, left atrial TxB2 levels were significantly higher (p < 0.05) than right atrial levels at all study points during CPB. After pulmonary reperfusion, TxB2 levels in both atria increased significantly (p < 0.02) compared with the levels before cross-clamping of the aorta, and there was an increasing gradient between the two atria (p < 0.05). Mean plasma TxB2 levels during CPB in group 2 were significantly reduced (p < 0.0001) in the right atrium (by 73%) and in the left atrium (by 69%) compared with levels in group 1. CONCLUSIONS The rise in TxB2 levels in the left atrium after CPB in humans reflects production of Tx mainly in the lungs, most probably by ischemic pulmonary tissue and intravascular hematologic components. Aspirin markedly reduces Tx production during CPB, and it might play a major role in preventing pulmonary injury after operations with CPB in humans.

Relationship between changes in thyroid hormone level and severity of the postoperative course in neonates undergoing open-heart surgery.

Background:  Our aim was to determine whether the changes in thyroid function after open‐heart surgery in neonates depend on the postoperative course.

Chest reconstruction in asphyxiating thoracic dystrophy

Asphyxiating thoracic dystrophy is a rare, complex malformation with a broad spectrum of clinical expression. Surgery is indicated only in severe cases in which failure to intervene will result in progressive pulmonary damage and eventual death. Conventional surgical techniques for expanding the thoracic cage diameter by sternotomy and the insertion of a metal prosthesis for anterior chest wall stability usually provide these patients with the time needed for thoracic cage growth. However, some of the most severe cases may require a two-stage approach. Hence, management should be directed toward resolving immediate ventilatory problems and minimizing secondary damage to the lungs caused by prolonged ventilatory support.

Coronary artery operation in patients after breast cancer therapy.

OBJECTIVE The purpose of this investigation was to retrospectively study the outcome of patients undergoing coronary artery operation who were previously treated for breast cancer. METHODS Between July 1992 and December 1996, 28 patients with a history of breast cancer underwent coronary artery bypass graft operation and were randomly matched against a noncancer group of similar size (n = 36) to allow for comparison of their preoperative characteristics, operative course, and postoperative outcome. RESULTS The incidence of sternal wound infection was significantly higher in the cancer group than in the control group (25% versus 6%; p = 0.027). Postoperative noncardiac chest pain occurred more frequently in the cancer group than in the control group (52% versus 31%; not significant). In the study group, radiotherapy and recent myocardial infarction were the only two independent factors associated with sternal wound complications. Patients with a less than 17-year interval between the breast cancer therapy and the coronary artery operation had a higher incidence of sternal wound infection (46%) as opposed to patients with a longer time interval (7%; p = 0.028; odds ratio = 12). Sternal wound complications were more frequent in patients with a history of right-sided breast cancer (50%) compared with left-sided lesions (12.5%; p = 0.068; odds ratio = 7). CONCLUSIONS Coronary artery operation in patients after breast cancer therapy may be associated with an increased sternal wound infection rate. To decrease this risk of infection, an approach through a right thoracotomy, minimally invasive techniques, the use of skeletonized internal mammary artery, and broad spectrum antibiotic therapy may be considered.

Successful resuscitation of a patient with acute massive pulmonary embolism using emergent embolectomy

Acute massive pulmonary embolism is associated with a high mortality rate. Prompt diagnosis and treatment are mandatory for a successful outcome. Although thrombolysis is effective, it is associated with a high rate of bleeding complications. This report describes the use of emergent pulmonary embolectomy as an effective and aggressive therapeutic approach to a massive saddle pulmonary embolism in a 66-year-old woman. With the application of specific surgical techniques and good interdisciplinary cooperation, pulmonary embolectomy may serve as more than a last resort for the management of this clinically unstable and dangerous condition.

Is the heart a source for elevated circulating endothelin levels during aorta—coronary artery bypass grafting surgery in human beings?

Reports have shown increased systemic levels of endothelins during coronary artery bypass grafting in human beings. It was not known whether increased endothelin levels during coronary artery bypass grafting reflect a general systemic response to the surgical procedure or increased myocardial production of endothelins in response to ischemia and reperfusion. We therefore measured endothelin levels in the right atrium and proximal aorta of 15 patients undergoing coronary artery bypass grafting for anginal syndrome immediately before aortic crossclamping and again after cessation of cardiopulmonary bypass. In five patients, we also measured coronary sinus levels of endothelins during cardiopulmonary bypass circulation. We found that endothelin levels were elevated throughout the surgical procedure. Right atrial endothelin levels were significantly elevated after cessation of cardiopulmonary bypass circulation with respect to values immediately before aortic crossclamping (11.1 +/- 3.1 vs 14.2 +/- 3.7 pg/ml, p = 0.008), whereas endothelin levels in the proximal aorta did not rise significantly (10.5 +/- 2.3 vs 11.6 +/- 2.4 pg/ml, p > 0.5). Coronary sinus endothelin levels tended to decline temporarily during cardiopulmonary bypass circulation (11.1 +/- 2.1 pg/ml before aortic crossclamping, 7.9 +/- 1.9 1 minute after release of aortic crossclamp, and 9.9 +/- 2.1 pg/ml after release of partial aortic crossclamping, p = 0.06). We conclude that the rise in right atrial endothelin levels during coronary artery bypass grafting reflects systemic production and secretion of endothelins, probably by vasculature or organs distal to the proximal aorta, and is not the result of increased myocardial production and secretion of endothelins.

Transesophageal echocardiography evaluation and follow-up of left main coronary artery patch angioplasty.

OBJECTIVE Isolated ostial stenosis of the left main coronary artery is a rare but serious condition. The treatment is surgical with two options: coronary artery bypass grafting or surgical angioplasty of the left main coronary artery. Assessing surgical results as well as follow-up were traditionally done by angiography. METHODS We describe the use of transesophageal echocardiography (TEE) for evaluating and follow the surgical left main coronary artery (LMCA) angioplasty results in eight patients with isolated ostial left main stenosis. RESULTS All patients were alive and free of ischemic events 8 months to 7 years post-surgery. TEE demonstrated a widely opened left main coronary artery with a good flow. CONCLUSIONS Surgical angioplasty is an alternative option for treating ostial LMCA stenosis. TEE is an additional excellent non-invasive technique for assessing left main anatomy pre- and postoperatively, as well as being on of the quality control tools for evaluating new surgical techniques.

Establishment of a heart valve homograft bank using existing facilities.

THE PROGRESS of cryobiology together with broadening surgical indications have increased the demand for heart valve homografts. Cryopreserved aortic valves have been implanted either in the sub-coronary position or as a complete aortic root replacement. Reconstruction of the right ventricular outflow tract for various forms of congenital heart defects has been performed with aortic or pulmonary homografts. Pulmonary valve homografts have been used for right ventricular outflow reconstruction during the “Ross” procedure. Mitral valve homografts are used for the replacement of the mitral valve in female patients of child-bearing age and in other patients who bears contraindications for anticoagulation. The disadvantages of homografts include limited availability and durability. Although some authors claim the durability of cryopreserved homograft to be superior to that of fresh homografts, other studies did not affirm this, and the different results are probably related to some extent to variability in the sterilization and the preservation protocols. On the other hand, it is widely agreed that cryopreservation increases the shelf life of homografts from a few weeks of the fresh antibiotic-preserved material to at least 5 years among cryopreserved grafts. Thus the problem of availability may be partly solved by using cryopreservation rather than “fresh” grafts, and by establishing more homograft laboratories (“banks”) in remote areas. Establishing an independent homograft bank is costly. We sought to establish an independent bank at no additional cost as a model that can be implemented in any medical center containing some form of tissue bank (eg, a bone marrow bank).